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Event Notification Report for May 1, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/30/2002 - 05/01/2002

                              ** EVENT NUMBERS **

38885  38886  38887  38888  

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|Hospital                                         |Event Number:   38885       |
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| REP ORG:  VA MEDICAL CENTER                    |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  VA MEDICAL CENTER                    |NOTIFICATION TIME: 15:35[EDT]|
|    CITY:  SAINT LOUIS              REGION:  3  |EVENT DATE:        04/30/2002|
|  COUNTY:                            STATE:  MO |EVENT TIME:             [CDT]|
|LICENSE#:  24-00144-5            AGREEMENT:  N  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  LARRY CHANDLER               |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| VA REPORTS LOST RADIOACTIVE MATERIAL LATER LOCATED IN A LANDFILL             |
|                                                                              |
| "1.   Part 20.2201(a) [telephone report]:                                    |
|                                                                              |
| a. A telephone report was not made since the circumstances related to the    |
| loss of licensed materials were identified to the licensee by the Nuclear    |
| Regulatory Commission (NRC) and are not based on specific information        |
| verified by the license or on official records.                              |
|                                                                              |
| b. Neither the NRC nor the state regulatory agency (Illinois Department of   |
| Nuclear Safety) with purview over the landfill has provided the licensee any |
| information other than telephone summaries and digital photographs.          |
|                                                                              |
| C. The estimate of the quantity of lost licensed materials was completed     |
| post hoc and is not based on measurements performed by the licensee.         |
|                                                                              |
| d. The licensee became aware of loss of licensed materials on March 29,      |
| 2002.                                                                        |
|                                                                              |
| 2. Part 20.2201(b)(i) [description of the licensed material involved,        |
| including kind, quantity, and chemical and physical form]:                   |
|                                                                              |
| a. The licensed material was I-131 as identified by spectral analysis at the |
| landfill by the state regulatory agency. Since the material could not be     |
| recovered, the exact chemical form could not be determined. However, in      |
| light of subsequent investigation, the form was probably inorganic NaI bound |
| to Sephadex  beads.                                                          |
|                                                                              |
| b. The gamma factor for I-131 is 2.2 R./hr per mCi @1cm.                     |
|                                                                              |
| c. The state regulatory agency reported the following exposure rates         |
| measured using a Bicron internal chamber meter.                              |
|                                                                              |
| (1) 125 mR/hr @  contact                                                     |
|                                                                              |
| (2) 50 mR/hr through side of truck                                           |
|                                                                              |
| (3) 0.65 mR/hr @ 1 meter                                                     |
|                                                                              |
| d. The three different readings appear to be somewhat contradictory.         |
| However, since the actual distance for the first two measurements is         |
| uncertain and less error is likely in exposure rate measurements at a known  |
| distance. the third measurement is considered the most accurate to use to    |
| estimate activity.                                                           |
|                                                                              |
| e. The waste materials from the laboratory were not specifically recovered   |
| or identified. The following three possible basis were used to estimate      |
| activity: the exposure rate measurements by the state regulatory agency, the |
| usual laboratory protocols, and recreation of exposure rate measurements in  |
| a laboratory setting.                                                        |
|                                                                              |
| (1) Using corrected distances for the exposure rate measurements and the     |
| gamma factor for I-131, the measurement at one meter calculates to an        |
| estimated activity of approximately 3 mCi.                                   |
|                                                                              |
| (2) The usual laboratory protocol is to use either 1 or 2 mCi  I-131 run     |
| through a column. The highest activity possible on the column is 1.9 mCi,    |
| corresponding to a maximum doping of 2 mCi, with the poorest binding success |
| of 5%.                                                                       |
|                                                                              |
| (3) Laboratory measurements were taken using a 16 uCi I-131 capsule and a GM |
| detector calibrated to CS-137 and with a thick-walled tube. The exposure     |
| rate measurement at contact with the thin plastic container with the capsule |
| nearest the probe was 45 mR/hr. This represents the closest likely proximity |
| implied by  contact.  Under this geometry, a reading of 125 mR/hr could be   |
| produced by as little as 44 uCi I-131. However, the rate drops to less than  |
| 0.05 mR/hr at 6 inches, due in part to the influence of the beta component.  |
| This indicates an activity in the millicurie range was involved in the       |
| incident, and the  contact  exposure rate measurement was likely not taken   |
| at contact, but at about 8 cm.                                               |
|                                                                              |
| (4) The estimate for activity is approximately 2 mCi.                        |
|                                                                              |
| 3. Part 20.2201(b)(ii) [a description of the circumstances under which the   |
| loss or theft occurred]:                                                     |
|                                                                              |
| a. The loss of licensed materials involved the Roxanna, Illinois, landfill.  |
| The loss was identified by the landfill operator during routine radiation    |
| monitoring for incoming waste shipments on March 28, 2002. The landfill      |
| operator reported higher than expected radiation monitoring results and      |
| notified the state regulatory agency. The state contacted the NRC. The NRC   |
| contacted the VA National Health Physics Program who then contacted the      |
| licensee.                                                                    |
|                                                                              |
| b. The loss involved I-131 contaminated glassware which was identified in a  |
| truck hauling waste from the licensee to the landfill. The landfill is       |
| approximately 20 miles from the licensee, John Cochran Division, in downtown |
| St. Louis: The waste was probably generated in a research laboratory in      |
| Building 1 of the John Cochran Division.                                     |
|                                                                              |
| c. Workers assigned to the licensee Environmental Management Service (EMS)   |
| collect waste at the end of each work day from research laboratories. The    |
| waste is initially placed in carts and then relocated to a dumpster at the   |
| loading dock. The contract waste carrier empties the waste collected in the  |
| dumpster on a daily basis, normally at night. The waste is then transported  |
| to a transfer station and consolidated with other waste. The consolidated    |
| waste is relocated to the landfill using a semi-trailer.                     |
|                                                                              |
| 4. Part 20.2201(b)(iii) [a statement of disposition. or probable             |
| disposition, of the licensed material involved]                              |
|                                                                              |
| a. Disposition of the radioactive materials was under the purview of the     |
| state regulatory agency.                                                     |
|                                                                              |
| b. The state regulatory agency directed the landfill operator to bury the    |
| waste materials.                                                             |
|                                                                              |
| 5. Part 20.2201(b)(iv) [exposures of individuals to radiation, circumstances |
| under which the exposures occurred, and the possible total effective dose    |
| equivalent to persons in unrestricted areas]:                                |
|                                                                              |
| a. The following individuals had the most potential for exposure             |
|                                                                              |
| (1) EMS (Environmental Management Service, i.e.  Housekeeper) personnel      |
| picking up waste and transporting it to dumpster                             |
|                                                                              |
| (2) Driver of truck hauling waste from VA to transfer point ( first truck )  |
|                                                                              |
| (3) Driver of truck hauling consolidated waste from transfer point to        |
| landfill ( 2nd truck )                                                       |
|                                                                              |
| (4) State of Illinois (IDNS) responding personnel                            |
|                                                                              |
| (5) Landfill personnel were not involved in the effort to recover the        |
| contaminated object. The potential exposure of personnel other than the      |
| above must be considered small in comparison.                                |
|                                                                              |
| b. Estimated exposure                                                        |
|                                                                              |
| (1) EMS workers                                                              |
|                                                                              |
| Estimated duration of exposure = 10 min (0.16 hr)                            |
| Average proximity 3 feet (bag of waste is carried in large cart with other   |
| bags)                                                                        |
| Inverse-square correction, using 0.65 mR/hr at 1.13 meters 0.83 mR/hr        |
| Add 20% for lack of shielding by dump truck =1.0 mR/hr                       |
| Estimated exposure 1.0 mR/hr x 0.16 hr = 0.16 mR                             |
|                                                                              |
| (2) Driver of first truck                                                    |
|                                                                              |
| Estimated duration of exposure 1 hr                                          |
| Average proximity = 10 feet (3 m)                                            |
| Inverse square correction, using at 0.65 mR/hr @ 1.13 m. through truck bed   |
|                                                                              |
| 0.65 mR/hr x (1.13/3)squared = 0.09 mR/hr                                    |
|                                                                              |
| Total estimated exposure: 1 hr x 0.09 mR/hr = 0.09 mR                        |
|                                                                              |
| (3) Driver of 2nd truck (semi-trailer) .                                     |
|                                                                              |
| Estimated duration of exposure = 1 hr                                        |
| Average proximity 17 feet (5 m)                                              |
| Inverse square calculation, staring at 0.65 mr/hr @ 1.13 m, through truck    |
| bed                                                                          |
|                                                                              |
| 0.65 mR./hr x (1.13/5) squared = 0.03 mR/hr                                  |
|                                                                              |
| Total estimated exposure: 1 hr x 0.03 mR/hr =0.03 mR                         |
|                                                                              |
| (4) IDNS responding personnel = N/A; occupationally exposed and monitored    |
|                                                                              |
| 6. Part 20.2201(b)(v) [actions that have been taken, or will be taken, to    |
| recover the material]:                                                       |
|                                                                              |
| a. Disposition of the radioactive materials was under the purview of the     |
| state regulatory agency.                                                     |
|                                                                              |
| b. The state regulatory agency directed the landfill operator to bury the    |
| waste materials.                                                             |
|                                                                              |
| c. The licensee attempted to recover the material by driving to the          |
| landfill, prior to being informed that the material had been buried. The     |
| licensee does not have any authority to take further actions to recover the  |
| material nor is recovery currently possible.                                 |
|                                                                              |
| 7. Part 20.2201(b)(vi) [procedures or measures that have been, or will be,   |
| adopted to ensure against a recurrence of the loss or theft of licensed      |
| material]:                                                                   |
|                                                                              |
| a. Investigation by the licensee verified that current policies and          |
| procedures regarding waste control are adequate and should have prevented    |
| such an incident. At some point, therefore, procedures were apparently not   |
| followed. Lab workers can not recall any breach of procedures. Similar waste |
| has been produced many times in the past without incident, and the           |
| ergonomics of the laboratory do not point to any probable mis-step.          |
| Therefore, remediation efforts will be broader than a focus on handling of   |
| the specific type of waste in question.                                      |
|                                                                              |
| b. The corrective actions will involve screening of all waste generated from |
| areas where external radiation detectable by NaI instruments is produced.    |
| All laboratories possessing photon-producing isotopes of energies greater    |
| than approximately 20 KeV, in quantity greater than 1 micro-curie, will be   |
| required to screen all sanitary and DIS waste with a NaI detector prior to   |
| release into the environment. The new standards will require that equipment, |
| procedures, and competency of screeners be reviewed and approved by the RSO  |
| for each area. The level of detail in the existing procedure for screening   |
| of DIS waste has been increased to include removing interposed shielding,    |
| measuring each container at multiple positions, using the most sensitive     |
| scale, and a standard for the background reading. This more detailed         |
| procedure will be applied to all labs utilizing DIS, and will also be        |
| applied to screening of sanitary waste by those labs required to do so. The  |
| procedure will be reviewed by the Radiation Safety Committee on May 2, 2002. |
| Users will be required to implement the new procedure by June 1, but will    |
| probably do so earlier. NaI detectors have been ordered; first deliveries    |
| are expected by the May 1. Until the equipment arrives and the program is    |
| fully implemented, routine trash pickups of affected areas has been halted.  |
| All waste is screened by the RSO, using the limited NaI technology currently |
| available, before release.                                                   |
|                                                                              |
| c. The requirement for sanitary waste screening will become a condition      |
| during both permit approval and renewal, and whenever an affected isotope is |
| added to the authorization. This condition will apply equally in Nuclear     |
| Medicine and Research laboratories at the St. Louis site of use.  RSO review |
| of equipment specifications and operator competency will be included in the  |
| approval process. This program has already been implemented.                 |
|                                                                              |
| d. Certain logistics of the waste-handling process, such as: how long waste  |
| is accumulated before screening, whether waste storage is centralized, arid  |
| how unscreened waste is stored, etc., can only be developed through          |
| practice. However, once  best practices  are developed, affected labs will   |
| be required to adopt diem, and will not be allowed to change them without    |
| review and approval of the RSO. Logistics will be under review through May,  |
| 2002; final practices will be in place by June 1, 2002.                      |
|                                                                              |
| e. DIS procedures and compliance will continue to be monitored during        |
| routine inspections and the results reported to the Radiation Safety         |
| Committee.                                                                   |
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|Other Nuclear Material                           |Event Number:   38886       |
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| REP ORG:  FMC IDAHO LLC                        |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  FMC IDAHO LLC                        |NOTIFICATION TIME: 15:37[EDT]|
|    CITY:  POCATELLO                REGION:  4  |EVENT DATE:        04/29/2002|
|  COUNTY:  POWER                     STATE:  ID |EVENT TIME:        15:30[MDT]|
|LICENSE#:  11-27071-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:  03032191                             |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BLAIR SPITZBERG      R4      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES RICE                   |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|IBBE 30.50(b)(2)         SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MALFUNCTIONING (RUPTURED), CESIUM-137, INSERTION SOURCE ON A BERTHOLD     
  |
| DENSITY DEVICE AT FMC IDAHO LLC IN POCATELLO, IDAHO                          |
|                                                                              |
| Prior to the event, a representative from FMC Idaho LLC (an elemental        |
| phosphorous plant which has been shutdown) contacted Thermo Measure Tech     |
| (used to be TN) to remove several density devices at the plant.  The plan    |
| was to have several devices removed, packed up, and shipped back to Thermo   |
| Measure Tech.                                                                |
|                                                                              |
| During the process of removing a Berthold (model number LB300, serial number |
| 2576-10-94) device with a 15-millicurie, cesium-137, insertion source (used  |
| to monitor tank levels), the cable which lowers the source pellet into the   |
| tube parted.  Workers improvised, got a hold of the wire, and pulled it back |
| up.  When the source came out of the top, it became obvious that it had      |
| ruptured.  All of the contaminated items (the source, a rag, a pair of       |
| gloves) were then put back into the tube, and the top was placed back on.    |
| The area was surveyed, and there was no contamination outside of the tube.   |
| Everything was locked up, and the area was marked off.                       |
|                                                                              |
| The licensee contacted Berthold USA.  Because the device was manufactured in |
| Germany, Berthold USA notified Berthold in Germany.  The licensee            |
| anticipates that Berthold will arrange to take possession of the device.  A  |
| manufacturer representative told the licensee that they had never had one of |
| these devices rupture in this fashion before.                                |
|                                                                              |
| The licensee notified the NRC Region 4 office (Christine Maier and Mark      |
| Shaffer).                                                                    |
|                                                                              |
| (Call the NRC operations center for a licensee contact telephone number.)    |
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|Power Reactor                                    |Event Number:   38887       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 04/30/2002|
|    UNIT:  [] [2] []                 STATE:  WI |NOTIFICATION TIME: 17:26[EDT]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        04/30/2002|
+------------------------------------------------+EVENT TIME:             [CDT]|
| NRC NOTIFIED BY:  RICK ROBBINS                 |LAST UPDATE DATE:  04/30/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PRESSURIZER SAFETY VALVE SETPOINT DRIFT AT POINT BEACH UNIT 2                |
|                                                                              |
| "On April 24, 2001, a vendor conducting offsite testing of the Point Beach   |
| Nuclear Plant (PBNP) Unit 2 RCS pressurizer safely valves' reported that     |
| safety valve 2RC-435 failed to lift at a test pressure of 2660 psig. The     |
| lift pressure specification for this valve is from 2440 to 2551 psig. In     |
| accordance with code requirement, the second in-service Unit 2 pressurizer   |
| safety valve was sent to the vendor for set point testing. The vendor also   |
| initiated an investigation to determine why the first valve failed to lift.  |
|                                                                              |
| "On April 29, 2002, our engineering department received a telecopy report of |
| that investigation. After evaluation, we determined this event to be         |
| reportable at 1129, 4-30-02. The valve at position 2RC-435 was last tested   |
| in November 2000 by the same vendor. At that time the valve set point was    |
| determined to be within specification. In accordance with the vendor's       |
| normal practice, a jack and lap procedure was done following the set point   |
| test to lap the valve disc and nozzle to insure that the valve is leaktight  |
| with undamaged seats. It was during this process that the valve became       |
| incapable of lifting at the specified pressure. The valve assembly was       |
| corrected and the set point retested with satisfactory results. The second   |
| safety valve that was shipped for testing subsequent to the failure of the   |
| first valve has also been tested and was found to lift within the specified  |
| range. Our investigation of the circumstances of the event is continuing.    |
|                                                                              |
| "The required design capacity for the RCS pressurizer safety valves assumes  |
| the use of 2 valves based on RCS pressure not exceeding the maximum code     |
| allowable 110% of design pressure for the maximum calculated in surge of     |
| reactor coolant into the pressurizer. We have concluded that we operated     |
| PBNP Unit 2 with one inoperable pressurizer safety valve for the past cycle. |
| The second Unit 2 safety valve has been tested and proven to be operable.    |
| This event is reportable both as a condition prohibited by the Technical     |
| Specification (LCO 3.4.10) and as an event or condition that resulted in an  |
| unanalyzed condition that had the potential to significantly degrade plant   |
| safety. An evaluation of the significance of this condition will be          |
| performed."                                                                  |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
+------------------------------------------------------------------------------+

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|Power Reactor                                    |Event Number:   38888       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: ARKANSAS NUCLEAR         REGION:  4  |NOTIFICATION DATE: 04/30/2002|
|    UNIT:  [] [2] []                 STATE:  AR |NOTIFICATION TIME: 19:13[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] CE                  |EVENT DATE:        04/30/2002|
+------------------------------------------------+EVENT TIME:        18:01[CDT]|
| NRC NOTIFIED BY:  JAMES PORTER                 |LAST UPDATE DATE:  05/01/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNUSUAL EVENT         |BLAIR SPITZBERG      R4      |
|10 CFR SECTION:                                 |SUSIE BLACK          NRR     |
|AAEC 50.72(a) (1) (i)    EMERGENCY DECLARED     |TIM MCGINTY          IRO     |
|                                                |RENE ZAPATA          FEMA    |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Hot Standby      |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNUSUAL EVENT AT ANO2 DUE TO BORON RESIDUE AT PRESSURIZER HEATER
SLEEVE N-2  |
|                                                                              |
| "On 4/30/02, while performing a planned Reactor Coolant System Integrity     |
| Inspection following the 2R15 refueling outage, with the Reactor Coolant     |
| System at normal operating temperature and pressure (Mode 3), an inspector   |
| discovered small traces of boric acid on pressurizer heater sleeve N-2.      |
| Based on the subsequent evaluation, pressurizer heater sleeve N-2 has been   |
| determined to have had pressure boundary leakage. No current leakage is      |
| detectable. The Unit 2 Tech Spec 3.4.6.2 does not allow operation in Modes   |
| 1-4 with any pressure boundary leakage. Therefore a plant cooldown is being  |
| initiated to place Unit 2 in Mode 5. Based on this criteria, the condition   |
| is reportable upon declaring a Notification of Unusual Event (EAL 2.1) and   |
| Degraded Condition which is reportable per 1OCFR50.72(b)(3)(ii)(A)".         |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
|                                                                              |
| * * *  UPDATE ON 5/1/02 @ 0331 BY AHO TO GOULD * * *                         |
|                                                                              |
| NOUE terminated at 0221CDT.  Plant in mode 5 (cold shutdown)                 |
|                                                                              |
| The NRC Resident Inspector will be notified.                                 |
|                                                                              |
| Notified FEMA(Zapata), REG 1 RDO(Spitzberg), EO(Black) and IRO(McGinty)      |
+------------------------------------------------------------------------------+